Group treatment settings that include both current and former smokers provide an invaluable opportunity for interactions that challenge the belief that smoking cessation is harmful to sobriety. In individual treatment settings, smokers might be directly encouraged to seek information from former smokers to “test” the hypothesis that smoking cessation increases the risk of relapse to alcohol(Drug information on alcohol) and other drug use. This type of strategy, referred to as “collaborative empiricism” in cognitive therapy terms,12 is preferable to confrontation or challenge as a means of promoting attitudinal change in that it tends to strengthen rather than strain the therapeutic alliance, which is critical to the effectiveness of any intervention.
Recognizing and building motivation to quit
“I got to thinking . . . what good is it if I stop drinking and still smoke? Nicotine(Drug information on nicotine) is a drug, too, right? I figure that while I am in here I might as well try to stop smoking too. If I just do all the things that I do to not pick up a drink, the same things should work for cigarettes.”
Another common myth that has impeded the widespread provision of smoking cessation interventions for individuals in substance abuse treatment is the characterization of substance abusers as intractable cigarette smokers who are largely uninterested in quitting. Much like the hypothesis that smoking cessation is harmful to sobriety, this theory has not held up to scientific scrutiny. Numerous studies have found that a significant proportion of substance abusers in treatment are interested in quitting and will take advantage of the opportunity to stop using all drugs of abuse simultaneously.2,13 In fact, we have often heard patients make spontaneous comparisons between tobacco and abuse of other drugs in terms of causes, consequences, and the process of quitting, which is consistent with the goals of integrative treatment for nicotine and other substance dependence.
Nonetheless, there are undoubtedly smokers who are not interested in quitting or who are not ready to quit while they are in a substance abuse treatment program. Brief motivational interventions should be provided for all unmotivated smokers. The Clinical Practice Guideline14 provides a useful mnemonic to guide brief motivational interventions: the “5 R’s.” These are the exploring of Risks of continued smoking; discussing the Relevance (personal reasons that quitting might be important) and Rewards of quitting; identifying and addressing Roadblocks to success; and Repetition of the motivation-enhancing intervention.
As indicated by the last of the 5 Rs, persistent attention to smoking cessation by treatment providers conveys the message that this is an important issue. Repetition also takes into account the dynamic nature of motivation to quit and the possibility that smokers may change their mind about quitting in a few days, weeks, or months.
Smoking cessation is challenging but achievable
“Quitting drugs is hard, but quitting smoking is harder. I am really proud of myself for doing this. If I can quit smoking, what else can I do?”
There are a number of reasons smoking cessation may be particularly difficult during early abstinence from alcohol and other substance use. For example, symptoms of nicotine withdrawal may be less tolerable in the context of concurrent withdrawal from other substances. There may also be some reluctance to give up what is sometimes described by patients as the last remaining mechanism for coping with the heightened physical and psychosocial stress that often accompanies early abstinence from alcohol and illicit drugs.
The results of a recent meta-analysis suggest that the quit rates of substance abusers in active treatment who received a smoking cessation intervention were lower than the quit rates in individuals with longer-term sobriety (ie, 12% in active treatment vs 38% in recovery quit with assistance at end of treatment).15 This finding is consistent with the notion of greater difficulty of smoking cessation during early abstinence from alcohol and other drugs.
An important finding from this meta-analysis is that the efficacy of smoking cessation treatment is not different for patients in active treatment than for those in recovery. That is, although the absolute quit rates were higher for individuals in recovery, the effect sizes of the interventions were not significantly different. The relative risk was 1.77 for those in recovery (ie, treatment increased the probability of quitting by 77%) and 2.03 for those in substance abuse treatment (ie, those who received treatment were twice as likely to quit as those who received the control intervention).15 This finding suggests that smoking cessation interventions almost double the likelihood of successful quitting compared with no treatment or placebo treatment, regardless of length of abstinence from alcohol and other drugs.